Postoperative Pain Management

Is the Surgical Team Approach Finally Getting It Right?

Michael A. Ramsay, MD, FRCA

Disclosures

Annals of Surgery. 2019;270(2):209-210. 

Good analgesia is a goal after major surgery. This does not necessarily equate to a pain score of zero, but does mean analgesia that provides well-tolerated pain relief and allows for early mobilization. Many different modalities of postoperative pain management have been studied with multiple meta-analyses and clinical trials having been published. This is especially the case for open liver surgery, which is one of the more challenging surgeries for providing good postoperative analgesia. Different and sometimes contradictory results on the optimal analgesic technique may be found in these manuscripts, especially in regard to the use of thoracic epidural analgesia.[1–10] Two manuscripts in this month's Annals of Surgeryexemplify the different findings, but also demonstrate how different centers may have different results.[1,2] There is no doubt that many factors affect the success of thoracic epidural analgesia and the reduction of complications. The most important factor is the technical expertise of the anesthesiologist, but the postoperative management by the perioperative team is also a critical factor for early mobilization and return to normal function.

The concerns that many physicians have with the management of epidural anesthesia for open liver surgery include the increased risk of a neuraxial hematoma resulting from a postoperative coagulopathy. In some centers this has resulted in the reluctance to using the modality and in others to withholding of venous thromboembolism (VTE) prophylaxis until the prothrombin time-derived international normalized ratio (PT-INR) has returned to less than 1.5. This, in some centers leads to the administration of fresh frozen plasma to correct the PT-INR. A review of the National Surgical Quality Improvement Program data for extended hepatic resections, the VTE rate has been reported as high as 5.8%.[11] This exceeds the rate for most major abdominal surgeries including colectomy. It has now been well established that many of these patients with an increased PT-INR have normal or increased coagulable states and do need VTE protection.[12]

The success of epidural anesthesia to provide optimal pain management for open liver surgery requires the formation of a surgical team. An experienced team approach leads to greater success, including the reduction of complications, early mobilization and discharge home, and thereby increased patient safety.[3]

Postoperative analgesia still continues to be inadequately managed in many centers.[13] However, Kehlet and Wilmore,[14] have developed enhanced recovery pathways (ERPs) after surgery that have resulted in early mobility and discharge, good pain management with multimodal analgesia and reduced or opioid-free therapy, and reduced morbidity and mortality.[15] Protocols that promote ERPs have become more frequently used and the evidence to support these protocols is getting stronger. Randomized clinical trials have shown that ERPs are effective as long as each member of the perioperative team is well versed in the protocols, carries them out effectively, and the data are collected and monitored.[16–21] These protocols are not just reliant on 1 anesthetic technique but rather rely on the experience of all team participants to be expert in the techniques used. The team must consist of the surgeon, anesthesiologist, perioperative nurses, pharmacy staff, physical and respiratory therapists, and the patient, together with a coordinator who collects the data and helps to demonstrate what is or is not working. This will enable the team and the hospital to track progress, provide education, and more importantly to learn where they are having success and what areas need improvement. The surgical team should have regular meetings to discuss patient management.

Local expertise at each center will dictate if thoracic epidural analgesia is used or if transversus abdominis plane (TAP) nerve blocks along with rectus sheath blocks are employed, or some other pain management modality. What is required is that evidence-based data demonstrates that the technique is effective and that a reliable surgical team has been put in place. Centers where thoracic epidurals have a high complication rate, such as a significant failure rate, neuraxial hematomas, hypotension, and increased fluid administration, may be better served using a different modality. Centers using TAP blocks must be able to demonstrate effectiveness of this technique. The use of ultrasound for accurate needle placement and deployment of the local anesthetic is optimal, together with images that can be reviewed later. If the block is placed by direct vision intraoperatively, care must be taken that the local anesthetic is placed on the TAP and not in the preperitoneal space. Good training and experience of the surgical team is a prerequisite to have a high and reliable degree of success.

When the surgical team approach is used consistently and evidence-based protocols for preoperative, intraoperative, and postoperative pain management are employed, together with center-specific data collection, significant improvements in patient care can be obtained. Regular review of the data collected is needed so that improvements may be initiated where indicated and also to monitor compliance with the protocols. When goal-directed fluid therapy and the use of nonopioid analgesics such as low-dose intravenous ketamine, oral acetaminophen, and gabapentin, are used together with maintaining normothermia, omitting nasogastric tubes and surgical drains, early mobilization, and early recovery may be consistently obtained. More importantly, perioperative opioids may be severely limited or totally avoided, resulting in less postoperative nausea and vomiting and early return of bowel function.[22] The ERP protocol must also contain guidelines for prescribing pain medications at discharge. This again should be multimodal with a goal of limited or zero opioids.

The overall goal is safe, effective care of our patients, good analgesia, early mobilization, avoiding or minimizing opioids, and early discharge home with minimal complications. This will result in both improved patient experience and reduced hospital costs.

Epidural analgesia will be right for some centers and TAP blocks for others. Reduction in opioid use in hospitals and their prescription for postoperative pain is known to reduce the incidence of opioid tolerance, addiction, and abuse in populations.[23–26]

The conclusion is that a team-based approach is optimal, utilizing the best techniques that must be based on center-specific data. The best methods of enhanced recovery for the center should be implemented and continuously improved based on sound evidence. This is the basis of a high reliability organization that we all, including the patient, want to accomplish. High reliability organizations cultivate resilience and consistency in results, by relentlessly prioritizing safety and excellence over other performance pressures, and this must be the expectation of our surgical teams.

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